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WI%Wm ass a <br /> INTERNATIONAL ANALYSIS REQUt <br /> AND Reference Document No M 7 9 <br /> TECIMOLOGY CHAIN OF CUSTODY RECORD* Page 1 of .• <br /> CORPORATION <br /> Project Name/No I J*,I1u- 1170,716Samples Shipment Date 7 _3���� __ - Bill to 5 ZT C3=JZ3;:''JS 4EVET <br /> --- � <br /> {3ample Team Members 2 ---C> "A"N Lab Destination a_ _ Gq n <br /> Profit Center No 3 �y/ _ _ l_ab Contact 9_ F-. N Gr.>u'r-r— --- --- -_ __- - -- <br /> Project Manager 4 K+'BiK� 7P Project Contact/Phone 1�.D'W39!K'?Q�i }Report to 10�-� ? v� <br /> Purchase Order No 6 Camer/Waybill No 13 <br /> Required Report Date 11 ` � _-_ • • i ---- - - -- <br /> En <br /> Samph 14 $ems 15 Dete/Tmne16 Container) mple1 Pre• 19 Tend" 20 Condit on 21 D� � 22 <br /> Number Collected T Volume serradraa m R Record No. <br /> m <br /> o�3og2Mrv/ G�u+�w e - �5r5 Voa� 400't Kms-- -- `4(G-)/5rey N OWN w one <br /> 2, <br /> iAµt SD <br /> CL <br /> L�^ O <br /> �3ZM(!JZ ��pU^�Ll)Atr� IZ!V [Inp"*- f +f. re <br /> I z gar <br /> CD <br /> Cr <br /> T� 4 <br /> a <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample Disposal. 25 Cr <br /> Non-hazard.La' Flammable J Skin Irritant 1A Poison B IJ Unknown IJ Return to Client. Disposal by Leb�. Archive [mos) <br /> Lnn <br /> Turnaround Time Required 26 DC Level 27 <br /> Normal Rush1J E II III IJ Project Specific (s ec ] <br /> 1 Relinquished28 Date 3- SI -4 Z 1 Received by 28 Date C <br /> {5ignature/Affihahon) Time ISVmWWAffifiauoni Time o <br /> 2 Relinquished by Date _ 2 Received by Date <br /> J9gnawre/A(fiheba,i Time Ognawre/A(firiewn) Time <br /> 3 Relinquished by Date __ 3 Received by Date <br /> i5ignaUn/AffihaWl Time Time <br /> Comments 29 <br /> Mr-A 3+1"1 <br />